Canada’s approach to migration h ealth September 28, 2016 Michael Mackinnon

1. Canada’s approach to migration health September 28, 2016 Michael Mackinnon

2. How Canada understands migration health How Canada’s approach to immigration affects the health of migrants What Canada can learn from the RCM Overview

3. How Canada understands migration health

4. Migrant populations initially healthier than Canadian born but their health advantage diminishes over time • Measures/evidence: • Self reported health • Rates of chronic diseases • Disability • Mental health • Refugees at greater risk of having poor health compared to other migrant groups What is the healthy immigrant effect? Share of Immigrants and Canadian-Born Self-Reporting as Healthy1

5. Those who choose to migrate, often posses a higher standard of living in their country of origin • Access to health-care, water, and sanitation services • Are able to afford medication or a more balanced diet (avoiding vitamin and mineral deficiencies) • They typically have greater control over their lives and environment than others in their country of origin • Less exposure to manual and risky employment; able to choose neighbourhood to live in; able to manage stress in lives • Even in the situation of forced migration, most often youngest/healthiest who move • With the recent Syrian movement: Although greater dental health needs have been observed, overall cohort has had relatively low health care costs • However, some say their health appears to be better due to: • Under-utilization of medical services due to lack of access, awareness, or cultural and linguistic barriers Why are immigrants healthier when they come to Canada?

6. Reduced community or family based supports • Loss of socio-economic status • Often means a reduction in capabilities to participate fully in society and to take full control over their lives • Can lead in turn to chronic stress and increase risk of a number of diseases, in particular heart disease3 And why does their health decline over time while living in Canada? Share of Immigrants Self-Reporting as “Healthy” by Participation in Organizations2

7. Other factors that may be in play • Adverse affects from new northern climate • Vitamin D Deficiency study4 • Adoption of poor health behaviours in destination country • High cost of housing in some Canadian cities, differences in built environments • Neighbourhoods with fewer resources and services5 • ‘Walkability’ of neighbourhood or community5 • Availability and accessibility in neighbourhood/community of grocery stores (selling fresh produce) versus fast food places5 And why does their health decline over time while living in Canada? (cont’d)

8. How Canada’s approach to immigration affects the health of migrants

9. Canadian economic immigration process emphasizes economic profiles that select individuals who are ‘best fit’ for Canada - family and humanitarian immigration to a much lesser extent • A portion of individuals that come to Canada apply as skilled immigrants through the Express Entry Category • This category uses the Comprehensive Ranking System (CRS)6 • Items assed include: • skills • work experience • language ability • education and other factors • Additional points awarded for having ajob offer or a provincial nomination • Individuals in this category tend to have a higher standard of living in their country of origin, usually meaning better health indicators; this further skews the healthy immigrant effect Selection based on human capital

10. Canada has a system of health screening and all immigrant categories require a medical exam for their application • Canada’s Immigration Medical Exam (IME) includes7: • a review of medical history • a physical examination and mental examination • radiology • laboratory tests • A medical assessment is then done based on the results of the IME. • This can reinforce the healthy immigrant effect by screening out public health risks and applicants with potentially costly health conditions • May also have a deterrent effect - discouraging those who are less healthy from applying *A more detailed presentation on Canada’s health screening will be presented later on today by Dr. Valerie Hindle, who is the Director of the Regional Medical Office – Ottawa at IRCC. Health screening prior to coming to Canada

11. In Canada, provinces and territories have primary responsibility for providing health care services (federal supports or some groups) • New permanent residents are eligible for provincial health insurance with at most a short (up to 3 months) wait period8 • Federally funded supports • Grant all permanent residents access to a wide array of services under the Settlement Program • Settlement Program – provides recent migrants with: needs assessment and referrals; information and orientation; language training and skills development; labour market access; and community connections9 • Specialized supports also exist to meet immediate and essential needs of resettled refugees (considered most vulnerable group of migrants) • Resettlement Assistance Program (RAP)9– income support and resettlement needs • Interim Federal Health Program (health-care coverage) – new pre-departure medical services will be introduced in April 2017 Integration and supports once in Canada

12. Community-based health information services promote mental health awareness and access to health care services for all newcomers including LGBTQ clients • Some clinicians in Canada recommend against systematic screening for posttraumatic stress disorder • Suggest that health practitioners be alert for associated signs and symptoms (e.g., unexplained somatic symptoms, sleep disorders or mental health disorders, such as depression or panic disorder) • Targeted programs to encourage use community-based services • Nova Scotia Brotherhood Initiative in Halifax Regional Municipality10 - gender and culturally appropriate primary health-care services • Women’s-only language classes – may cover issues as women’s health, parenting, family violence, women’s rights, and spousal abuse Classification (le cas échéant) … Including federal funding for supports at the community level

13. What Canada can learn from the Regional Conference on Migration

14. Given that Canada looks to screening to prevent communicable disease outbreaks in Canada… • What are the patterns of risk of infectious diseases seen in the region? • What regionally specific (tropical) communicable diseases does the region have? • How should we adjust our screening so that we can address the risk(s) present? Patterns of risk when dealing with communicable diseases

15. Given that we look to integrate people quickly into the Canadian health-care system… • Are there region-specific precursor health conditions that Canadian health professionals should monitor in recent migrants? • Are there cultural/dietary concerns? • e.g. foods deficient in certain vitamins/minerals; heavy rich foods that could lead to cardiovascular disease • Are there specific genetic predispositions?12 • Cardiovascular Disease • Various types of Cancer • Diabetes • Asthma Patterns of risk when looking at specific populations

16. We are aware of the types of risks currently being faced in the region… • Unexpected migrant flows impacting border communities; placing excessive demands on public services already stretched thin • Identifying and monitoring health risks and needs; with increased risks from migrant populations with low vaccination rates • Tracking and documenting of large influx of transitory migrants • Managing large numbers of returnees and deportees with diminished operational and financial capacities • Limited epidemiological surveillance and strained clinical capacity for dealing with natural disasters But… • What can the RCM tell us about the impacts on their health, and how best to manage these? Patterns of risk in forced & irregular migration

17. How can we better recognize risks specific to this region? What factors prior to migration could become barriers to migrants’ integration? How can we better maintain the healthy immigrant advantage once people arrive in Canada? What have been some success stories? There is more Canada can learn…

18. References • "Health Status and Social Capital of Recent Immigrants in Canada: Evidence from the Longitudinal Survey of Immigrants to Canada." Government of Canada. May 11, 2010. Accessed July 26, 2016. http://www.cic.gc.ca/english/resources/research/immigrant-survey/section5.asp. • “Health Status and Social Capital of Recent Immigrants in Canada: Evidence from the Longitudinal Survey of Immigrants to Canada”, [2010] Jun Zhao, Li Xue, and Tara Gilkinson. • Marmot, Michael. The Status Syndrome - How Social Standing Affects Our Health and Longevity. New York, New York: Henry Holt and Company, LLC, 2004. • Aucoin, Michael, Rob Weaver, Roger Thomas, and Lanice Jones. "Vitamin D Status of Refugees Arriving in Canada." Canadian Family Physician 59, no. 4 (April 2013): 188-94. http://www.cfp.ca/content/59/4/e188.full.pdf.html. • Taylor, Gregory, Dr. "The Chief Public Health Officer’s Report on the State of Public Health in Canada 2014: Public Health in the Future." Public Health Agency of Canada. September 2014. Accessed August 30, 2016. http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2014/index-eng.php. • "Entry Criteria and the Comprehensive Ranking System." Government of Canada. May 28, 2015. Accessed August 2, 2016. http://www.cic.gc.ca/english/express-entry/criteria-crs.asp. • "Immigration Medical Exam (IME)." Government of Canada. May 07, 2013. Accessed August 30, 2016. http://www.cic.gc.ca/english/resources/tools/medic/exam/index.asp. • "Canada's Universal Health-care System." Government of Canada. June 03, 2016. Accessed August 30, 2016. http://www.cic.gc.ca/english/newcomers/after-health.asp. • "Settlement Program and Resettlement Assistance Program (RAP)." Government of Canada. March 23, 2016. Accessed August 30, 2016. http://www.cic.gc.ca/english/department/grants-contributions-funding/. • "N.S. Launches Health Program for Young, Black Men." The Chronicle Herald, June 23, 2016. Accessed August 30, 2016. http://thechronicleherald.ca/novascotia/1374924-n.s.-launches-health-program-for-young-black-men. • Pottie, Kevin, MD MCISc, Christina Greenaway, MD MSc, Ghayda Hassan, PhD, Charles Hui, MD, and Laurence J. Kirmayer, MD. "Caring for a Newly Arrived Syrian Refugee Family." Canadian Medical Association Journal 188, no. 3 (January 11, 2016): 207-011. Accessed September 20, 2016. doi:10.1503/cmaj.151422. • "Genes and Noncommunical Diseases." World Health Organization. 2016. Accessed August 30, 2016. http://www.who.int/genomics/public/geneticdiseases/en/index3.html.